Liu Jerome H, Zingmond David S, McGory Marcia L, SooHoo Nelson F, Ettner Susan L, Brook Robert H, Ko Clifford Y
Center for Surgical Outcomes and Quality, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, Calif, USA.
JAMA. 2006 Oct 25;296(16):1973-80. doi: 10.1001/jama.296.16.1973.
Referral to high-volume hospitals has been recommended for operations with a demonstrated volume-outcome relationship. The characteristics of patients who receive care at low-volume hospitals may be different from those of patients who receive care at high-volume hospitals. These differences may limit their ability to access or receive care at a high-volume hospital.
To identify patient characteristics associated with the use of high-volume hospitals, using California's Office of Statewide Health Planning and Development patient discharge database.
DESIGN, SETTING, AND PARTICIPANTS: Retrospective study of Californians receiving the following inpatient operations from 2000 through 2004: elective abdominal aortic aneurysm repair, coronary artery bypass grafting, carotid endarterectomy, esophageal cancer resection, hip fracture repair, lung cancer resection, cardiac valve replacement, coronary angioplasty, pancreatic cancer resection, and total knee replacement.
Patient race/ethnicity and insurance status in high-volume (highest 20% of patients by mean annual volume) and in low-volume (lowest 20%) hospitals.
A total of 719,608 patients received 1 of the 10 operations. Overall, nonwhites, Medicaid patients, and uninsured patients were less likely to receive care at high-volume hospitals and more likely to receive care at low-volume hospitals when controlling for other patient-level characteristics. Blacks were significantly (P<.05) less likely than whites to receive care at high-volume hospitals for 6 of the 10 operations (relative risk [RR] range, 0.40-0.72), while Asians and Hispanics were significantly less likely to receive care at high-volume hospitals for 5 (RR range, 0.60-0.91) and 9 (RR range, 0.46-0.88), respectively. Medicaid patients were significantly less likely than Medicare patients to receive care at high-volume hospitals for 7 of the operations (RR range, 0.22-0.66), while uninsured patients were less likely to be treated at high-volume hospitals for 9 (RR range, 0.20-0.81).
There are substantial disparities in the characteristics of patients receiving care at high-volume hospitals. The interest in selective referral to high-volume hospitals should include explicit efforts to identify the patient and system factors required to reduce current inequities regarding their use.
对于已证明存在手术量-预后关系的手术，建议转诊至高手术量的医院。在低手术量医院接受治疗的患者特征可能与在高手术量医院接受治疗的患者不同。这些差异可能会限制他们进入高手术量医院或在那里接受治疗的能力。
利用加利福尼亚州全州卫生规划与发展办公室的患者出院数据库，确定与使用高手术量医院相关的患者特征。
设计、设置和参与者：对2000年至2004年接受以下住院手术的加利福尼亚人进行回顾性研究：择期腹主动脉瘤修复术、冠状动脉搭桥术、颈动脉内膜切除术、食管癌切除术、髋部骨折修复术、肺癌切除术、心脏瓣膜置换术、冠状动脉成形术、胰腺癌切除术和全膝关节置换术。
高手术量（按年均手术量排名前20%的患者）和低手术量（最低20%）医院中的患者种族/族裔和保险状况。
共有719,608名患者接受了10种手术中的1种。总体而言，在控制其他患者层面特征后，非白人、医疗补助患者和未参保患者在高手术量医院接受治疗的可能性较小，而在低手术量医院接受治疗的可能性较大。在10种手术中的6种手术中，黑人在高手术量医院接受治疗的可能性显著低于白人（P<0.05）（相对风险[RR]范围为0.40-0.72），而亚洲人和西班牙裔在高手术量医院接受治疗的可能性分别在5种手术（RR范围为0.60-0.91）和9种手术（RR范围为0.46-0.88）中显著较低。在7种手术中，医疗补助患者在高手术量医院接受治疗的可能性显著低于医疗保险患者（RR范围为0.22-0.66），而未参保患者在9种手术中在高手术量医院接受治疗的可能性较小（RR范围为0.20-0.81）。
在高手术量医院接受治疗的患者特征存在显著差异。对选择性转诊至高手术量医院的关注应包括明确努力识别减少当前在使用高手术量医院方面的不公平现象所需的患者和系统因素。
